2 Application Part 2 (PDF)

BACKGROUND AUTHORIZATION
A People 2.0 Affiliate

First Name:

Middle Name: ________________Last Name:__________________________

Social Security Number:_______________________
Maiden Name (if applicable):

Date of Birth:

*

*This information will be used for background screening purposes only.

Current Address
Address

Prior Address
Address

City

City

State

Zip

County
Driver’s License Number:

State

Zip

County
License State:

I acknowledge receipt of the BACKGROUND DISCLOSURE FORM REGARDING BACKGROUND INVESTIGATION and
A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (add link here) and certify that I have
read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative
consumer reports” by People 2.0 through the above Affiliate, People 2.0’s local authorized agent at any time after receipt of
this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any
law enforcement agency, administrator, state or federal agency, institution, school or university (public or private),
information service bureau, employer, insurance company or other party to furnish any and all background information
requested by a third party, another outside organization acting on behalf of People 2.0 and its Affiliate. I agree that a
facsimile (“fax”) or electronic or photographic copy of this Authorization shall be as valid as the original.

State of Washington applicants and employees only: You have the right to receive a complete and accurate disclosure of the
nature and scope of any investigative consumer report as well as a written summary of your rights and remedies under
Washington law.
Massachusetts and New Jersey applicants and employees only: You have the right to inspect and promptly receive a copy of
any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above
directly.
New York applicants and employees only: You have the right to inspect and receive a copy of any investigative consumer
report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below,
you also acknowledge receipt of Article 23-A of the New York Correction Law.
Minnesota applicants and employees only: You have the right, upon written request to Agency, to receive a complete and
accurate disclosure of the nature and scope of any consumer report. Agency must make this disclosure within five days of
receipt of your request or of Company’s request for the report, whichever is later. Please check this box if you would like to
receive a copy of a consumer report if one is obtained by the Company. 
Oklahoma applicants and employees only: Please check this box if you would like to receive a copy of a consumer report if
one is obtained by the Company. 
California applicants and employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING
BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a
copy of an investigative consumer report at no charge if one is obtained by the Company whenever you have a right to
receive such a copy under California law. 

Signature:

Date:

For CALIFORNIA EMPLOYEES BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW
With People 2.0 through its Affiliate, Abc Staffing
People 2.0 through the above Affiliate, People 2.0’s local authorized agent, intends to obtain information about you
from an investigative consumer reporting agency and/or a consumer credit reporting agency for employment
purposes. Thus, you can expect to be the subject of "investigative consumer reports" and "consumer credit reports"
obtained for employment purposes. Such reports may include information about your character, general reputation,
personal characteristics, and mode of living. With respect to any investigative consumer report from an investigative
consumer reporting agency ("ICRA"), the Company may investigate the information contained in your employment
application and other background information about you, including but not limited to, obtaining a criminal record
report, verifying references, work history, your educational achievements, licensure and certifications, obtaining
your driving record and other information about you, and interviewing people who are knowledgeable about you.
The results of this report may be used as a factor in making employment decisions. The source of any investigative
consumer report (as that term is defined under California law) will be People 2.0 ( Name address and phone number
of the entity doing the Check Criminal History with website address ), or another outside organization. The source
of any credit report will be ( Name address and phone number of the entity doing the Check Criminal History with
website address ), or another outside organization, Information regarding ( Name address and phone number of
the entity doing the Check Criminal History with website address ), or another outside organization (including
information about whether any consumer personal information will be sent outside the U.S. or its territories) may be
found at (enter company website address that is doing the background investigation)
The Company agrees to provide you with a copy of an investigative consumer report when required to do so under
California law.
Under California Civil Code section 1786.22, you are entitled to find out from an ICRA what is in the ICRA’s file on
you with proper identification, as follows:





In person, by visual inspection of your file during normal business hours and upon reasonable notice. You
also may request a copy of the information in person. The ICRA may not charge you more than the actual
copying costs for providing you with a copy of your file.
A summary of all information contained in the ICRA’s file on you which is required to be provided by the
California Civil Code and will be provided to you via telephone, if you have made a written request with proper
identification for telephone disclosure and the toll charge, if any, for the telephone call is prepaid by or charged
directly to you.
By requesting a copy be sent to a specified addressee by certified mail. ICRAs complying with requests for
certified mailings shall not be liable for disclosures to third parties caused by mishandling of mail after such
mailings leave the ICRAs.

"Proper Identification" includes documents such as a valid driver’s license, social security account number, military
identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require
additional information concerning your employment and personal or family history in order to verify your identity.
The ICRA will provide trained personnel to explain any information furnished to you and will provide a written
explanation of any coded information contained in files maintained on you. This written explanation will be provided
whenever a file is provided to you for visual inspection.
You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An
ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such
person’s presence.
3/2015 © People 2.0, Inc.

Reference Check
A People 2.0 Affiliate

Applicant

Last 4 of SSN _______________

I have applied for work with People 2.0 dba Hiregy Staffing and I am authorizing you to provide information regarding my
employment with your company. This includes any and all information regarding my service, character, and conduct while
employed with your company. I hereby release all parties from any and all liability which may result from supplying such
information.
Applicant Signature

Date ____________________________

To be completed by previous employer
1. What position did this employee hold at your company?
2. What were his/her dates of employment?
3. What was the salary? Starting Salary

Ending Salary

4. Did this employee have attendance problems? If yes, please explain

5. Was this employee’s performance satisfactory? Yes  No 
6.

Is this employee eligible for rehire? Yes  No 

7. Other Comments?

__

__

Verifier’s Information
Verifier’s Name:

Date:

Verifer’s Title:

Phone or email:

To be completed by Hiregy

Previous Employer

Supervisor Name

Phone Number

Fax or email Info

Rev. 11/2015